Modified cervicopexy: a novel, less-invasive technique for Stages III and IV uterine prolapse Ali M. Elsaman a , Hosam T. Salem a , Magdy Amin b , Ahmed N. Fetih a, *, Essam-Edin R. Othman a , Kamal M. Zahran a a Department of Obstetrics and Gynaecology, Faculty of Medicine, Assiut Woman’s Health Hospital, Assiut University, Assiut, Egypt b Sohage University, Sohage, Egypt Introduction Anterior abdominal wall cervicopexy (AWC) is a simple, effective uterine conservation strategy for treatment of Stages III and IV uterovaginal prolapse [1]. It is a straightforward procedure that can be taught easily to residents and young gynaecologists, especially in low-resource settings. Its costs, technical demands, operative time and complications are lower compared with other procedures [2–7]. Reported recurrences with AWC have mainly been iatrogenic due to cutting the supporting sutures during caesarean delivery. However, the original AWC procedure entails a laparotomy and requires direct intraperitoneal manipulation during obliteration of the pouch of Douglas. Furthermore, pelvic adhesions have been reported, and these are undesirable for young women who wish to retain their reproductive potential [1]. As such, the authors designed the modified AWC procedure. This is less invasive and safer than the original AWC procedure due to avoidance of formal laparotomy and direct manipulation of pelvic organs. Patients and methods After obtaining institutional review board approval, 17 cases with Stage III uterine prolapse and 13 cases with Stage IV uterine prolapse, presenting with a mass protruding through the vulva, inability to evacuate the bladder, dragging pains and/or rectal symptoms, were selected for this study. Cases who had completed their families, had associated genital pathology or had no desire to retain their uteri were excluded. Written consent was obtained from patients after detailed counseling and discussion of other affordable alternatives, such as use of a vaginal pessary, vaginal hysterectomy or sacral hysteropexy. The modified AWC procedure was performed under spinal anaesthesia with the patient in a lithotomy position. The procedure commenced with vaginal obliteration of the pouch of Douglas through approximation of the uterosacral ligaments with non- absorbable suture (Fig. 1). This step involved grasping the posterior cervical lip, opening the vaginal skin and peritoneum, and exposing the uterosacral ligaments (Figs. 2 and 3). The ends of the sutures were passed through the vaginal wall at the apex without passing European Journal of Obstetrics & Gynecology and Reproductive Biology 183 (2014) 159–163 A R T I C L E I N F O Article history: Received 19 August 2014 Accepted 10 October 2014 Keywords: Anterior abdominal wall Uterine suspension Cervicopexy Hysteropexy Uterine prolapse A B S T R A C T Objective: To evaluate modified anterior abdominal wall cervicopexy (AWC) as a less invasive (via 3-cm minilaparotomy) and more augmented (via securing posterior vaginal wall to uterosacral ligaments) technique. Methods: Case series of 30 women with Stages III and IV apical uterine prolapse assessed by the pelvic organ prolapse quantification system. Results: The modified AWC procedure was performed successfully for 17 cases with Stage III uterovaginal prolapse and 13 cases with Stage IV uterovaginal prolapse. The procedure was conducted safely with no operative or postoperative complications, apart from two cases with postoperative urinary retention. Operative time ranged from 45 to 70 min. Follow-up was available for 1–3 years. Overall, 27 cases were satisfied with the procedure, and three cases developed recurrence after caesarean section due to cutting the supporting sutures. Conclusions: The modified AWC procedure is less invasive, simple and effective for Stages III and IV uterine prolapse. ß 2014 Elsevier Ireland Ltd. All rights reserved. * Corresponding author. Dr. Ahmed N. Fetih, Department of Obstetrics and Gynaecology, Faculty of Medicine, Assiut University, PO Box 30, Assiut, Egypt. Tel.: +2 01224532883; fax: +2 0882337333. E-mail address: ahmedfetih@yahoo.com (A.N. Fetih). Contents lists available at ScienceDirect European Journal of Obstetrics & Gynecology and Reproductive Biology jou r nal h o mep ag e: w ww .elsevier .co m /loc ate/ejo g rb http://dx.doi.org/10.1016/j.ejogrb.2014.10.014 0301-2115/ß 2014 Elsevier Ireland Ltd. All rights reserved.